SACROILIITIS

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SACROILIITIS

Author: Rajesh Yadav

INTRODUCTION

Sacroiliitis is an inflammation of one or both of sacroiliac joints. The sacroiliac joints are found where the spine meets the pelvis.

The sacrum is a triangular bone at the bottom of the spine, below the lumbar region of spine and above the tailbone. It consists of five fused vertebral segments. The sacrum is connected to pelvic bone, also known as the iliac crest, on the right and left sides at the sacroiliac joints. These joints act as shock absorbing structures and typically only move a small amount. This is a long vertical joint and held together by multiple ligaments with many more pain fibers contained within it.

The sacrum is at the base of the spine and is subject to a great deal of stress.

Sacroiliitis can be presented with complain about pain in buttocks or the lower lumbar spine and normally gets worse when standing for a long period, walking and very commonly where transitioning from sitting to standing. This type of pain more often but sometimes it may associated with radiation of pain which radiates down the leg usually above the knee.

CAUSES OF SACROILIITIS

There are several potential causes of inflammation in sacroiliac joints. These includes:

  1. Sacroiliac dysfunction or the mobility of the sacrum itself is altered that can cause inflammation.
  2. Ankylosing spondylitis:- This is a progressive type of inflammatory arthritis that affects the spine and hips.
  3. Osteoarthritis: This can cause inflammation in sacroiliac joints and is another underlying cause of sacroiliitis.
  4. Trauma:- A sudden traumatic injury may damage the sacroiliac joints and cause inflamation, leading to sacroiliitis.
  5. Pregnancy:- When a woman is pregnant her sacroiliac joints stretched to room for growing baby. This may put stress on the joints and cause sacroiliitis.
  6. Infection:- If the sacroiliac joints get infected become inflamed.

Symptoms

  • The pain associated with sacroiliitis most commonly occurs in the buttocks and lower back and back of one or both legs.
  • Slight fever
  • Stiffness of the hips and lower back.
  • Sometimes sacroiliitis can cause pain in hips and feet too, although this is less common.

The following activities can aggravate sacroiliitis pain:

  • Sitting or standing for long periods.
  • Standing with weight on one leg.
  • Climbing the stairs
  • Taking long strides when walking
  • Running
  • Turning over in Bed
  • Getting out of the bed in morning.

Diagnosis 

Sacroiliitis may be hard to diagnose, as it can be mistaken for lower back pain caused by different condition so Diagnosis is made by careful history and complete neurological examination.

Patients with sacroiliitis can be diagnosed by having a normal neurological findings but with abnormal musculosketal findings.

  • Palpation over sacroiliac joints almost always reproduces the patients pain exactly.
  • Neurological examination fail to show any evidence of nerve root compression, “Pinched nerve”.
  • Special Test: like on the basis of below test is to stress sacroiliac joints and if any sacroiliac dysfunction is present it results in the reproduction of patient symptoms.
  1. The distraction test
  2. Thigh thrust
  3. Gaenslen’s test
  4. Compression test
  5. Sacral thrust
  6. FABER / the Patrick test

Other investigation also need for diagnosis of sacroiliitis, like

Blood Test

Complete Haemogram,

Inflammatory marker like – ESR, CRP, Platelets, RA Factor, HLAB27, Uric Acid level are must, where infective or inflammatory back pain is suspected.

Radiological

X-Ray – of pelvis can reveal signs of damage to sacroiliac joint.

MRI – if Ankyolosing Spondylitis is suspected may need MRI for further evaluation.

Diagnostic Intervention

By infiltrating local anesthetic over sacroiliac joint.

will this give pain relief to patient or not ?

After all investigation the most important evaluation of a patient of low back pain is to look for any RED FLAGS.

Red Flags are danger signs indicating serious underlying condition that needs immediate surgical interventions, like in

  • Trauma
  • Tumor
  • Infection
  • Neurological deficit

 

Treatment 

Treatment consists of various ways of relieving inflammation but it depends upon the sign & symptom as well as causes of sacroiliitis.

  1. CONSERVATIVE MANAGEMENT:
  2. Non pharmacological approach:–
  • Rest: Avoid the movements that aggravate sacroiliitis pain can help to reduce inflammation
  • ICE & Heat: Alternate placing ice and heat packs on the affected area may help in relieving sacroiliitis pain.
  • Hip flexion exercise: This exercise involves laying on the back with the leg supported by a pillow, cross on leg over another, squeeze the legs together then release. Repeat this on both sides.
  • Back School: A team generally used for group classes that provide education about back pain. They generally include information of the spine, common sources of low back pain, proper lifting techniques, advice about exercise and remaining active.
  • Reassurance and patient education

B).PSYCHOLOGICAL INTERVENTION

Chronic pain is associated with psychological disturbances and hence need proper counseling and treatment of associated depression and anxiety.

C).PHARMACOLOGICAL MANAGEMENT

Types of analgesic depend upon the type of pain and underlying etiology.

If pain is Nociceptive in nature (No tingling or burning0

  1. Then simple analgesic like Paracetamol at the dose of 3grams / day can be started and then dose decrees after 10 days. Although less effective than NSAIDs, it has less adverse effects and it safe. They are useful in mild to moderate pain.
  2. Non-Steroidal anti-inflamatory drugs (NSAIDs) are highly effective in acute low back pain but are limited by their serious adverse effects. Hence NSAIDs should be restricted to short duration (5-7 days).
  • Opiods: Weak opioids like Tramadol can be given in acute low back pain both as monotherapy and incombination with NSAIDs and Paracetamol.

If the pain has neuropathic component (tingling, numbness, burning, shooting)

  1. Pregabalin started with 75 mg once or twice a day and dose gradually increased depending on the patient tolerance.
  2. Gabapentin started with 100 mg thrice a day and dose is gradually increased, maximum dose upto 3600 mg/day.

If pain is of burning quality better responds to antidepressants like

  1. Amitriptyline – 5-10 mg and increased upto a maximum dose of 100mg/day.
  2. Nortriptyline – 5-10 mg/day

 

  1. INTERVENTIONAL PAIN MANAGEMENT:-

When low back pain persistence for more than 6 weeks with or without treatment and pain is more than mild, poorly respond to treatment with drugs. It require multi-modal approach to manage chronic low back pain, where intervention techniques are required.

  • Intra – articular local injection can be diagnostic followed by Steroid or Radio Frequency ablation as therapeutic procedures.

3.SURGICAL MANAGEMENT

It is a general rule that presence of RED-FLAGS warrants the surgical management in the most of the situation.

Failure of conservative and interventional management may also need surgical management. Although surgery is rarely use to treat sacroiliitis.

Fusion of the two bones together with metal hardware or other fusion devices may help in relieving sacroiliitis pain.

Reference:

 

  1. Spine-health.com
  2. Basics of Pain Management , 44-47,1 st edition, Gautam Das
  3. org
  4. Clinical Methods in Pain Medicine , 113-127, 2nd edition, Gautam Das